Alle barn har vondt i magen Av og til. Men hvorfor? Og må de ha det?

Transkript

1 Alle barn har vondt i magen Av og til. Men hvorfor? Og må de ha det? Fagdag Barne og ungdomshelse Anders Lindgren Overlege, St Olavs hospital

2 Kronisk forstoppelse (KO), IBS med obstipasjon (IBSo) og avføringsinkontinens (AI) hos barn og unge Vanlige og ofte undererkjente årsaker til magesmerter og mistrivsel hos barn En gjennomgang av årsaker, utredning og behandling

3 IBS IBS = Irritable Bowel Syndrome Ikke å forveksle med IBD (Inflammatory Bowel Syndrome; Ulcerøs kolitt, Crohns sykdom) IBS med obstipasjon IBS med diaré

4 Dagens mål Få overgripende kunnskap om diagnostikk, utredning, behandling og oppfølging av KO, IBSo og AI Kjenne igjen og finne frem til tilstandene Kunne gi god informasjon til barn, unge og foreldre for å sikre god behandling Vite hvor man kan finne ytterligere informasjon om tilstandene Til seg selv Til pasienten Ta død på noen myter

5 Definisjon kronisk funksjonell forstoppelse Rome III-criteria Diagnostic criteria* Must include two or more of the following in a child with a developmental age of at least 4 years with insufficient criteria for diagnosis of IBS: 1. Two or fewer defecations in the toilet per week 2. At least one episode of fecal incontinence per week 3. History of retentive posturing or excessive volitional stool retention 4. History of painful or hard bowel movements 5. Presence of a large fecal mass in the rectum 6. History of large diameter stools which may obstruct the toilet

6 Definisjon og vanlige symptomer IBS/IBSo Rome III-criteria Diagnostic criteria* Rome III Must include both of the following: 1. Abdominal discomfort or pain associated with two or more of the following at least 25% of the time: a. Improvement with defecation b. Onset associated with a change in frequency of stool c. Onset associated with a change in form (appearance) of stool 2. No evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the subject s symptoms Typiske symptomer: Magesmerter Varierende avføringskonsistens og mengde Ofte løs avføring flere ganger daglig og kun sjelden hard avføring. Den harde avføringen noteres ofte ikke av foreldrene. Borborygmi og økt flatulens Illeluktende avføring og gass Urgency (Springer ofte på toalettet ifb med middag)

7 Fekal inkontinens Definisjon Diagnostic criteria* Must include all of the following in a child with a developmental age at least 4 years: 1. Defecation into places inappropriate to the social context at least once per month 2. No evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the subject s symptoms

8 Epidemiologi Prevalensen av forstoppelse hos barn og unge er estimert til 0.7% til 29.6% i befolkningen i verden; de fleste barnen og unge har ingen åpenbar etiologisk bakgrunn. (Constipation in children. Tabbers MM, Boluyt N, Berger MY, Benninga MA. Clin Evid (Online) Apr 6;2010. doi:pii: 0303) Funksjonell forstoppelse hos barn og unge er meget vanlig, og står for opp til 25% av besøk på en barnegastroenterologisk poliklinikk. (Childhood constipation: finally some hard data about hard stools. Di Lorenzo C. J Pediatr 2000;136:4 7.) Prevalensen av IBS enlig Rom III kriteriene hos barn og unge var 22.6% og IBS med obstipasjon var den dominerende subtypen. (The Incidence of Irritable Bowel Syndrome in Children Using the Rome III Criteria and the Effect of Trimebutine Treatment. Karabulut GS, Beşer OF, Erginöz E, Kutlu T, Cokuğraş FÇ, Erkan T. J Neurogastroenterol Motil Jan;19(1):90-3. doi: /jnm Epub 2013 Jan 8) 5-10 barn som henvises til poliklinikken hver uke har underliggende KO, IBSo og/eller AI. Mange barn henvises akutt til Barn Mottak døgnet rundt. Mange inneliggende barn med kronisk sykdom behandles for KO. Noen barn er inneliggende pga KO.

9 Etiologi Sensitiv triad: 1. Ved oppstart morsmelkerstatning eller fast føde 2. Ved bleieslutt 3. Ved skolestart Ond sirkel: Hard avføring smertefull defækasjon tilbakeholding enda hardere avføring etc. redusert rektal sensibilitet redusert tømmingsrefleks Familial disposition/genetics Organic disease

10 Etiologi, forts. Men hvorfor blir egentlig avføringen hard? Maten? For lite drikke? For lite fysisk aktivitet? For lang tykktarm? Svar: Nei.

11 Etiologi, forts.

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13 IBSo og kronisk forstoppelse; andre symptomer Kroniske (intermitterende) magesmerter Inkl nattlige oppvåkninger Spiseproblemer; kresenhet, småspisthet ( fussy eater ) Hematochezia Anale fissurer Soiling ; urenhet Kvalme Oppkast; spesielt småbarn Irritabilitet, generelt nedsatt trivsel, fatigue Forverring etter inntak av fermenterende mat: Hvetebakst, pannekaker, risgrøt med mer Mistolkes ofte som laktoseintoleranse, cøliaki, kumelkproteinallergi etc FODMAP (Gibson, PR; Peter R Gibson and Susan J Shepherd (2010). "Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach". Journal of Gastroenterology and Hepatology 25 (2): doi: /j x. PMID ) Urinveisproblemer Dagenurese og nattenurese kan forverres av, eller årsakes av obstipasjon. Bedres/går over av vellykket obstipasjonsbehandlng. Residiverende urinveisinfeksjoner Hyperaktiv blære

14 Obstipasjon og urinveisplager Anorektal og lav urinveisfunksjon er relaterte. Dette kan føre til: Blæredysfunksjon, inklusive overreaktiv blære (urge) Økt eller minsket tømmingsfrekvens, og blære underaktivitet Denne relasjon mellom abnormal tarm- og blærefunksjon kalles noen ganger bowel bladder dysfunction eller eliminasjonssyndrom. Selv om blæredysfunksjon ofte er relatert til funksjonell obstipasjon, må nevrologiske tilstander ekskluderes. Vellykket obstipasjonsbehandling er en viktig komponent i å behandle blæredysfunksjonen.

15 Kronisk forstoppelse; bakenforliggende sykdommer: Hirschsprung s sykdom: Mekoniumavgang innen de første 24(48) hours? Smal avføringskaliber? Rektal eksplorasjon. Kumelkproteinintoleranse/-allergi (spes. Spedbarn) Vanligste symptomer er rektal blødning og/eller slim samt diaré Vanlig med perianale fissurer Cøliaki Hypothyroidism Anatomiske/nevrologiske malformasjoner (Spina bifida) Crohn s disease (small bowel)

16 Kronisk obstipasjon relatert til pottetrening og kumelkintroduksjon J Pediatr Gastroenterol Nutr Oct;55(4): Characteristics of intestinal habits in children younger than 4 years: detecting constipation. Mota DM1, Barros AJ, Santos I, Matijasevich A. OBJECTIVES: The aim of the present study was to describe the prevalence of childhood constipation, stool characteristics, and their relationship with toilet training and age of introduction of cow's milk. METHODS: A total of 4231 children born in 2004, from a birth cohort study, were assessed at 12, 24, and 48 months of age, when their mothers provided information on sociodemographic characteristics, bowel habits, toilet training, and age of introduction of cow's milk and other foods. RESULTS: The prevalence of constipation was 27.3% and 31.0% at 24 and 48 months of age, respectively. Among girls, at 48 months of age, it was 34.4% versus 27.4% in boys (P<0.001). The most common features of constipation were scybalous stools (47.7% and 41.0% at 24 and 48 months, respectively), evacuation difficulty (24.3% and 23.1%), and hard stools (17.8% and 34.1%). Toilet training starting before 24 months was associated with constipation at 24 months and its persistence up to 48 months. Among children who did not receive cow's milk in their first year of life, 22% had constipation at 24 months, 22.6% at 48 months, and 8.3% at 24 and 48 months. Among children who started cow's milk before 30 days of life, the respective proportions of children with constipation was 28.2%, 33%, and 12.4%. CONCLUSIONS: The prevalence of constipation increases with age and cannot be detected using only information on evacuation interval. Toilet training before 24 months and introduction of cow's milk before 1 year of age is positively associated with constipation at 24 months and its persistence up to 48 months

17 Obstipasjon relatert til livsstilsfaktorer tidlig i livet Early-Life Factors Associated With Pediatric Functional Constipation. pg DOI: /MPG Turco, Rossella *; Miele, Erasmo *; Russo, Marina *; Mastroianni, Rossella *; Lavorgna, Alessandra *; Paludetto, Roberto *; Pensabene, Licia +; Greco, Luigi *; Campanozzi, Angelo ++; Borrelli, Osvaldo [S]; Romano, Claudio ; Chiaro, Andrea ; Guariso, Graziella [P]; Staiano, Annamaria Conclusions: Our results confirmed that breastfeeding is a protective factor for FC in the first 3 months of life and that the female sex is at risk to have FC. We found that the use of acetaminophen was associated with a higher incidence of FC in the first year of life

18 Kronisk obstipasjon relatert til omsorgssvikt Journal of Pediatric Gastroenterology and Nutrition Issue: Volume 58(4), April 2014, p Association Between Child Maltreatment and Constipation: A School-Based Survey Using Rome III Criteria Rajindrajith, Shaman*; Devanarayana, Niranga M. ; Lakmini, Chamila*; Subasinghe, Vindya*; de Silva, D.G. Harendra*; Benninga, Marc A. ABSTRACT Objective: Child abuse leads to multiple physical and psychosomatic sequelae. The aim of the present study was to evaluate the association between child abuse and constipation among schoolchildren. Methods: Children 13 to 18 years of age were selected from 4 semiurban schools in Gampaha District, Sri Lanka. A self-administered questionnaire was used for data collection. Information regarding sociodemographic factors and gastrointestinal symptoms, child abuse, and somatisation were collected. Constipation was diagnosed using Rome III criteria. Results: A total of 1792 children were included in the analysis (boys 975 [54.4%], mean age 14.4 years, standard deviation [SD] 1.3 years). One hundred thirty-eight (7.7%) fulfilled Rome III criteria for constipation. The number of children exposed to physical, emotional, and sexual abuse were, respectively, 438 (24.4%), 396 (22.1%), and 51 (2.8%). The prevalence of constipation was significantly higher in those exposed to sexual (5.8% vs 2.6% = 0.03), emotional (40.9% vs 20.8%, < ), and physical abuse (41.6% vs 23.2%, < ). Mean somatisation score was higher in the total group of abused children with constipation (mean 18.6, SD 12.5) compared with those without (mean 13.9, SD 12.3; = 0.027). Children with a history of abuse did not seek health care more often than children without this history. Patient-perceived severity of bowel symptoms was higher in children with physical abuse (23.7 vs 19.7 = 0.001) and emotional abuse (25.4 vs 19.3 < ). Conclusions: Childhood constipation shows a significant association with physical, sexual, and emotional abuse. Children with constipation complain of more somatic symptoms and bowel symptoms when they are exposed to abuse.

19 Kronisk obstipasjon relatert til ADHD Association of constipation and fecal incontinence with attention-deficit/hyperactivity disorder. McKeown C, Hisle-Gorman E, Eide M, Gorman GH, Nylund CM Pediatrics Nov;132(5):e Epub 2013 Oct 21. OBJECTIVE: Functional constipation and fecal incontinence are common childhood gastrointestinal conditions. Both conditions may be associated with behavioral problems. Attention-deficit/hyperactivity disorder (ADHD) is the most common behavioral disorder of childhood, characterized by shortened attention span and hyperactivity. We hypothesize that a diagnosis of ADHD increases the risk for functional constipation and fecal incontinence. METHODS: A retrospective cohort study of children was performed by using the military health system database. Children of active-duty military personnel, aged 4 to 12 years, from October 2005 to September 2007, were included. ADHD, constipation, and fecal incontinence were identified by International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes. Relative risks and adjusted incidence rate ratios (IRRs) were calculated. A subgroup analysis of subjects receiving medical therapy was performed. RESULTS: There were children identified in the study, (4.4%) of whom had ADHD. Children with ADHD had an increased prevalence of constipation (4.1% of children with ADHD vs 1.5% children without ADHD; P<.001) and fecal incontinence (0.9% of children with ADHD vs 0.15% of children without ADHD; P<.0001). Children with ADHD had more visits than those without ADHD for both constipation (IRR 3.39; 95% confidence interval ) and fecal incontinence (IRR 7.74; 95% confidence interval ). Children with ADHD receiving medicinal therapy did not differ significantly from children with ADHD not receiving medicinal therapy on rates of constipation visits (P =.57) or fecal incontinence visits (P =.32). CONCLUSIONS: Children with ADHD are significantly more likely to have constipation and fecal incontinence. Medical therapy for ADHD does not impact visit rates for defecation disorders.

20 Kronisk obstipasjon relatert til Autismespekteret Autism spectrum disorders in children with functional defecation disorders. AU Peeters B, Noens I, Philips EM, Kuppens S, Benninga MA SO J Pediatr Sep;163(3): Epub 2013 Mar 22. OBJECTIVE: To prospectively assess the prevalence of autism spectrum disorder (ASD) symptoms in children presenting with functional defecation disorders. STUDY DESIGN: Children (age 4-12 years) with functional constipation or functional non-retentive fecal incontinence according to the Rome III criteria referred to a specialized outpatient clinic were included. Parents completed 2 validated ASD screening questionnaires about their child; the Social Responsiveness Scale (SRS) and the Social Communication Questionnaire-Lifetime (SCQ-L). A total SRS score of 51 is a strong indicator for the presence of ASD. On the SCQ-L, a score of 15 is suggestive for ASD. RESULTS: In total, 242 patients (130 males, median age 7.9 years) were included. Of these, 91% were diagnosed with functional constipation and 9% with functional non-retentive fecal incontinence. Thirteen children (5.4%) had previously been diagnosed with ASD. Twenty-six children (11%) had both SRS and SCQ-L scores at or above cutoff points, strongly suggestive for the presence of ASD. Solely high SRS were present in 42 children (17%), whereas two children (1%) only had high SCQ-L scores. Altogether, 29% had ASD symptoms, indicated by SRS and/or SCQ-L scores at or above the cutoff values. These children were older than children without ASD symptoms and presented with a longer duration of symptoms. CONCLUSIONS: A substantial number of children (29%) presenting with a functional defecation disorder at a tertiary hospital has concomitant ASD symptoms. Clinicians should be aware of ASD symptoms in children with functional defecation disorders.

21 Kronisk obstipasjon relatert til sosiologiske og miljømessige faktorer Journal of Pediatric Gastroenterology and Nutrition Issue: Volume 55(1), July 2012, p Socioenvironmental Factors Associated With Constipation in Hong Kong Children and Rome III Criteria. Tam, Yuk H. *; Li, Albert M. +; So, Hung K. +; Shit, Kam Y. *; Pang, Kristine K. *; Wong, Yuen S. *; Tsui, Siu Y. *; Mou, Jennifer W. *; Chan, Kin W. *; Lee, Kim H. * AB Objective: Data regarding the prevalence of constipation in the general population of Asian children using internationally standardized definitions are scarce. Environmental factors surrounding a child's day to day living may trigger or perpetuate constipation and encourage postponement of defecation. Methods: A territory-wide cross-sectional questionnaire survey was conducted in 2318 Hong Kong Chinese elementary school students. Constipation was defined by pediatric Rome III criteria. Results: The mean age of the children was 9 +/- 1.9 years; 51% were boys. Two hundred eighty-two children (12.2%, 95% confidence interval [CI] 10.9%-13.5%) were found to have constipation. Children ages 6 to 7 years had the highest prevalence (16.8%, 95% CI 13.8%-19.8%). There was no difference in prevalence between boys and girls (11.6% vs 12.3%; P > 0.05) and between obese and nonobese children (11.5% vs 11.1%; P > 0.05). In univariate analysis, constipation was found to be significantly more prevalent among those children who lived with neither parent, had inadequate company of parents at home, refused to pass bowel movements in school, spent long hours doing homework, had inadequate sleep, and had decreased fiber intake and frequent consumption of fast food (P < 0.05). Multivariate analysis identified refusal to pass bowel movements in school toilets (odds ratio [OR] 1.97, 95% CI 1.42%-2.74%), having dinner with one/both parents <50% of time (OR 1.52, 95% CI 1.01%-2.31%), nighttime sleep <7 hours (OR 1.87, 95% CI 1.04%-3.33%), and frequent consumption of fast food (OR 1.14, 95% CI 1.03%-1.26%) to be independent factors associated with constipation. Conclusions: Socioenvironmental factors are associated with childhood constipation, and bringing them to the awareness of the public may help prevent or stop the progression of childhood constipation at its early stages. Copyright 2012 by ESPGHAN and NASPGHAN

22 Borowitz SM, Cox DJ, Kovatchev B, Ritterband LM, Sheen J, Sutphen J. Related Articles, Links Treatment of childhood constipation by primary care physicians: efficacy and predictors of outcome. Pediatrics Apr;115(4): CONCLUSION: Primary care physicians tend to undertreat childhood constipation. After 2 months of treatment, nearly 40% of constipated children remain symptomatic.

23 RESULTS: After 2 months of treatment, 44 (37%) of 119 children remained constipated. In the majority (87%) of cases, physicians prescribed some form of laxative or stool softener. In nearly all cases, a specific fixed dose of laxative was recommended; in only 5% of cases were parents instructed clearly to adjust the dose of laxative up or down to get the desired effect. In approximately half of the cases, physicians recommended some sort of dietary intervention.

24 RESULTS, forts. In 45% of cases, physicians prescribed disimpaction using oral cathartics, enemas, or suppositories followed by daily laxatives. In 35% of cases, physicians prescribed daily laxatives without any disimpaction procedure. In the remainder, physicians prescribed only dietary changes (5%), the use of intermittent laxatives (9%), or no therapy (7% Treatment success corresponded to how aggressively the child was treated. Specifically, children who underwent some form of colonic evacuation followed by daily laxative therapy were more likely to have responded to treatment than were those who were treated less aggressively.

25 Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN M.M. Tabbers, C. DiLorenzo, M.Y. Berger, C. Faure, M.W. Langendam, S. Nurko, A. Staiano, Y. Vandenplas, and M.A. Benninga

26 Diagnostikk (ESPGHAN, NASPGHAN) Based on expert opinion, we recommend the Rome III criteria for the definition of functional constipation for all age groups. Voting: 9, 9, 9, 9, 9, 9, 9, 9 Based on expert opinion, the diagnosis of functional constipation is based on history and physical examination. Voting: 9, 9, 9, 9, 9, 9, 9, 9

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28 Diagnostikk; undersøkelser (ESPGHAN, NASPGHAN) Rektal digital eksaminasjon Hvis kun 1 Rom III-kriterium er tilstede Ved alarmsignaler Røntgen abdomen Ikke rutinemessig Ved mistanke om KO men usikker undersøkelse Colon transittid Ikke rutinemessig UL rektumdiameter Ikke anbefalt

29 Diagnostikk; lab (ESPGHAN, NASPGHAN) Based on expert opinion, we do not recommend routine laboratory testing for hypothyroidism, celiac disease, and hypercalcemia in children with constipation in the absence of alarm symptoms. Voting: 7, 8, 8, 9, 9, 9, 9, 9

30 Diagnostikk; allergiutredning (ESPGHAN, NASPGHAN) Routine allergy testing is not recommended to diagnose cow s-milk allergy in children with functional constipation. Voting: 7, 7, 8, 8, 9, 9, 9, 9 (12) Based on expert opinion, a 2- to 4- week trial of avoidance of CMP may be indicated in the child with intractable constipation. Voting: 6, 6, 7, 7, 8, 8, 8, 9

31 Diagnostikk; differentialdiagnoser Celiac disease (ESPGHAN, NASPGHAN) Hypothyroidism, hypercalcemia, hypokalemia Diabetes mellitus Dietary protein allergy Drugs, toxics: Opiates, anticholinergics, Antidepressants, Chemotherapy, Heavy metal ingestion (lead), Vitamin D intoxication, Botulism Cystic fibrosis Hirschsprung Disease Anal achalasia Colonic inertia Anatomic malformations Imperforate anus Anal stenosis Pelvic mass (sacral teratoma) Spinal cord anomalies, trauma, tethered cord Abnormal abdominal musculature (prune belly, gastroschisis, Down syndrome) Pseudoobstruction (visceral neuropathies, myopathies, mesenchymopathies) Multiple endocrine neoplasia type 2B

32 Viktige punkter ved anamnesen og undersøkelsen av sped- og småbarn Sykehistorien: Starter noen uker postnatalt (Ikke ved fødselen) Åpenbare utløsende faktorer (diettendring, toaletttrening, infeksjoner, barnehagestart, nye søsken, flytt) Normal mekoniumpassasje (innen 24 tim) Undersøkelsen: God AT, normal vekst og vektutvikling Normalt utseende og beliggenhet av anus Bløt abdomen, normal hud lumbosakralt Normal tonus, reflekser i underekstremiteter

33 KO hos spedbarn Uvanlig med KO hos spedbarn som fullammes. Men eksisterer. Vanlig med KO hos spedbarn på morsmelkserstatning. Bør ikke bagatelliseres men behandles. Infantil dyschezi Ineffektiv defækasjon hos et ellers friskt spedbarn. Gråter og strever i ca 10 minutter før tømming. Normal, mjuk avføring. Går over spontant innen 6-9 mån alder.

34 Viktige punkter ved anamnesen og undersøkelsen av større barn og Anamnese: ungdommer Starter noen uker postnatalt (Ikke ved fødselen) Sammenfaller noen ganger med utløsende faktorer (diettendring, skolestart, infeksjoner, fissur, store familieendringer, angst, fobi, store familieendringer, reiser, nye medisiner) Normal mekoniumpassasje (innen 24 tim) Undersøkelse God AT, normal vekst og vekt, fysisk god form Samme som for spedbarn f.ø. Obs perianal GAS infeksjon

35 Andre vanlige symptomer ved IBS og KO Småspist/ kresen i maten Friskt blod i avføringen Analfissurer Siv av avføring i trusa/ bremsespor Kroniske magesmerter eller tilbakevendende magesmerter Kvalme Oppkast; spesielt små barn Utilpasshet/slapphet/irritabilitet Forverring av fermenterende mat. Ofte melkerik, sukkerrik og hvete gjærbakst. Disse symptomer forsvinner eller bedres etter oppstart av effektiv behandling. Assosiert dagenurese. Blærekontrollen bedres ofte når obstipasjonen behandles.

36 Kronisk obstipasjon Alarmsignaler Deby allerede ved fødsel eller under de første leveukene Mekoniumavgang senere enn 24(-48) timer (hos terminbarn) Smalkalibret avføring Kronisk oppblåst mage og oppkast/sprutbrekninger Unormalt plassert anus eller anal stenose Avflatende vekt- eller lengdeutvikling Neurologiske symptomer

37 Fekal inkontinens (1) (Enkoprese) Meget belastende tilstand for hele familien >90% er relatert til kronisk obstipasjon Ofte underliggende og forverrende psykologiske og psykososiale faktorer. Typisk er at barnen ikke kjenner at de har avføringsinkontinens. Behandle obstipasjonen! I de fleste alvorlige tilfeller, og tilfeller der obstipasjonsbehandling ikke hjelper bør BUP kobles inn.

38 Fekal inkontinens (2) (Enkoprese) Retentiv FI Tilbakeholdende adferd og obstipasjon med sekundær enkoprese Ikke-retentiv FI Ikke organisk enkoprese Relatert til psyke Omsorgssvikt, fysisk, seksuell eller psykisk misshandel, utviklingshemming, adferdsforstyrrelser Primær FI Barnet har aldri vært tørr Sekundær FI Oppstått etter at barnet lært normale toalettvaner.

39 KO, IBSo; behandling 1. Tømming 2. Vedlikeholdsbehandling Regelmessig avføring for å utvikle økt rektal sensibilitet og dermed unngå smertefull defækasjon og tilbakeholdende adferd. Toalettrutiner Aldri holde tilbake Altidgåpåtoalettet morgen og kveld. Etter måltid Laksantia 3-6 måneder? Ofte lenger

40 KO, IBSo; tømming PEG 3350 med elektrolytter; Movicol Klyster Oljeklyster (ev gitt i rektal sonde) min x 3-6 under 7-10dager Laxabon Gis som Dagbehandling med sonde Laxoberal 5-10 dråper vesper. Behandlingslengden skreddersys. Ikke veldig effektivt alene Lett å få i barn Tarmirritant; bør ikke brukes over mange måneder. Etc, etc

41 Tømming ( Disimpaction ) Movicol mixture (PEG 3350 with electrolytes) 1-1,5g/kg/d i 3-6dager > Oljeklyster 2 11 y: ml once/day >11 y: ml once/day

42 Tømming ( Disimpaction ) Movicol junior Ved avføringsstopp hos barn >5 år hvor rectum og/eller colon er fylt med fast fekalia: Barn 5-11 år: En behandlingskur ved avføringsstopp varer inntil 7 dager. Samme doser som Movicol men observer at hver pose innholder halve mengden (6,5g)

43 Laksantia Individuell dosering Etter god behandling i 1-2 måneder eller lengre, gradvis, langsom nedtrapping Obs tilbakevendendesymptomer Totalt sett 3-6 måneders behandling ved meget god adherence. Ved tilbakefall må man starte fra begynnelsen igjen.

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45 Behandling; Laksantia Movicol (13,125g) Osmotisk virkende laksantia Ikke tarmirriterende 0,2-0,8g/kg/d ¼ -½ pose daglig for barn 2-6 år Vi bruker det fra 1 års alder 1 pose daglig for barn 7-11 år 1-3 poser daglig for barn >11 år Movicol Junior (6,563g) Bedre smak, innholder ikke tilsats av sitrussmak. Reseptpliktig

46 Behandling; Laksantia: Laktulose /Duphalac(R) Osmotisk virkende laksantia Ikke tarmirriterende Kan være effektivt ved lettgradig/kortvarig obstipasjon Dosering: 1-3ml/kg/d i delte doser <1års alder; 5ml på morgenen 1-6 år; 5-10ml in 2 divided doses 6-14 år; 10-15ml >14 år; 10-25ml

47 Behandling; Laksantia: Flytende Parafin Effektiv Tolereres oftest godt. Kan blandes med saft eller juice. Fører ikke til malabsorbsjon av fettløslige vitaminer Fettpneumonitt ved aspiration* 1-3ml/kg/d Fekal inkontinens *Kontraindikasjoner Spedbarn <1 år Barn med alvorlige nevrologiske handicap Alvorlig GØRS eller svelgproblemer av andre årsaker

48 Behandling; mat, drikke og fysisk aktivitet (ESPGHAN/NASPGHAN) A normal fiber intake is recommended in children with constipation. Voting: 6, 8, 9, 9, 9, 9, 9, 9 Based on expert opinion, we recommend a normal fluid intake in children with constipation. Voting: 9, 9, 9, 9, 9, 9, 9, 9 Based on expert opinion, we recommend a normal physical activity in children with constipation. Voting: 9, 9, 9, 9, 9, 9, 9, 9 Fiber er bra. Ikke overdrevet inntak av melk. Maks 1-2 glass daglig. Youghurt er ikke stoppende.

49 Prognose (1) Den generelle oppfatningen på at kronisk obstipasjon blir bra hos de fleste, støttes ikke av forskning. Vedvarende symptomer hos 30 to 52% av barn i studier med minst fem års oppfølging. Kunnskap om outcome hos voksne er begrenset. En ny oppfølgingsstudie fra Nederland viser vedvarende symptomer inn i voksenlivet hos 24% av barn med KO. Samme studie viste at 88% av voksne med dårlig klinisk outcome, hadde vedvarende plager av KO og 21% hadde fortsatt FI. Dårlig klinisk outcome er relatert til sen deby. I en liten retrospektiv studie virker KO hos barn være en prediktor for IBS i voksenlivet.

50 Prognose (ESPGHAN/NASPGHAN) Av pasienter som henvises til barnegastroenterolog vil 50% bli bra uten laksantia innen 6-12 måneder. Ytterligere 10% vil være bra mens de tar laksantia. 40% vil fortsatt ha symptomer tross bruk av laksantia. 50% og 80% av barnen vil være bra etter henholdsvis 5 og 10 år og de fleste av dem vil ikke bruke laksantia. Ved henvisning til pediatrisk gastroenterolog vil en forsinkelse fra symptomdeby på >3måneder, medføre lengre symptomdurasjon. Det finnes ikke gode prognostiske parametre.

51 Til slutt: Ekstremt vanlige tilstander! Tenk alltid på KO og IBSo ved kroniske magesmerter, løs avføring, luftplager og diffuse mage-tarmplager. Behandlingen kan til stor del baseres på sundt fornuft. For en vellykket behandling kreves: Gode toalettvaner Tømming og vedlikeholdsbehandling med laksantia Meget god informasjon til barn og foreldre. Ansvarliggjøring av barnet; den som eier magen Gode rammer tilrettelagt av foreldre Langvarig fokus Individuell tilpasning av laksantiadoser

52 Spørsmål og kommentarer but maybe X